A Comparison of Temporalis Transfer and Free Latissimus Dorsi Transfer in Lower Facial Reanimation Following Unilateral Longstanding Facial Palsy

Facial reanimation using free partial latissimus dorsi muscle transfer: Single versus dual innervation method

The aim of the present study was to analyze the consequences of partial free latissimus dorsi muscle flap with nerve splitting technique (Partial LD transfer) for facial reanimation and compare outcomes according to innervation method (singer versus dual innervation). Patients with complete unilateral facial paralysis underwent either the single (ipsilateral masseteric nerve only) or dual (ipsilateral masseteric nerve plus contralateral buccal branch of the facial nerve) nerve innervation method for facial reanimation. An assessment was carried out to compare the outcomes between the single and dual innervation. Total of 21 patients were involved in this study. In the single innervation group, 7 out of 8 patients developed a voluntary smile. However, none were able to achieve a spontaneous smile. On the other hand, 9 out of 13 patients developed a voluntary smile and 3 out of 13 patients achieved a spontaneous smile. The mean increases of smile excursion assessed by Emotrics software and Terzis grades showed no significant differences between two groups. Within the limitations of the study it seems that partial LD transfer approach utilizing the dual innervation method has a positive effect on achieving a spontaneous smile and could be a valuable option for facial reanimation.

Dual-innervated multivector muscle transfer using two superficial subslips of the serratus anterior muscle for long-standing facial paralysis

Recent reports have described several cases of double muscle transfers to restore natural, symmetrical smiles in patients with long-standing facial paralysis. However, these complex procedures sometimes result in cheek bulkiness owing to the double muscle transfer. We present the case of a 67-year-old woman with long-standing facial paralysis, who underwent two-stage facial reanimation using two superficial subslips of the serratus anterior muscle innervated by the masseteric and contralateral facial nerves via a sural nerve graft. Each muscle subslip was transferred to the upper lip and oral commissures, which were oriented in different directions. Furthermore, a horizontal fascia lata graft was added at the lower lip to prevent deformities such as lower lip elongation and deviation. Voluntary contraction was noted at roughly 4 months, and a spontaneous smile without biting was noted 8 months postoperatively. At 18 months after surgery, the patient demonstrated a spontaneous symmetrical smile with adequate excursion of the lower lip, upper lip, and oral commissure, without cheek bulkiness. Dual-innervated muscle transfer using two multivector superficial subslips of the serratus anterior muscle may be a good option for long-standing facial paralysis, as it can achieve a symmetrical smile that can be performed voluntarily and spontaneously.

Facial Reanimation With Free Latissumus Dorsi Muscle Transfer, a Comparative Study Between Lateral and Supine Approach

ABSTRACT

In this article, the authors present the versatility of the Latissmus dorsi muscle as a donor option in facial reanimation and compare between different approaches in harvesting this muscle.The study included 24 Latissimus Dorsi (LD) functional muscles were transferred for smile reanimation of complete facial palsy. The patients were classified into 2 groups in which the muscle either harvested with supine or lateral (trans-axillary) approach. Muscle harvesting time, total operating times, blood loss, and bulkiness of the flap were analyzed and compared. The hypoglossal nerve was used in 14 cases, the masseteric nerve in 4 cases, and the lower trunk of the facial nerve was used in 6 cases as adonor nerve. No microvascular complications were observed, hematoma occurred in 2 cases only. No donor site complications in any of the cases.The trans-axillary approach provides less operative time, blood loss, and donor site morbidity, while the classic approach is easier and has the advantage of skin paddle in complex cases.

The sternohyoid muscle flap for new dynamic facial reanimation technique: Anatomical study and clinical results

BACKGROUND

Long-term facial nerve palsy has a highly negative impact on patients' quality of life. In 2016, Alam reported one case of facial reanimation with the sternohyoid muscle after publishing a preclinical study in 2013. Despite the potentially ideal characteristics of this muscle for reanimation of facial palsy, this technique is still not widely used. The objective of our description of cases was to present the clinical results obtained with the surgical procedure and the study on cadavers to confirm the anatomical findings.

METHODS

This work describes the anatomical study of the vascular and nervous pedicle of the sternohyoid muscle compared with clinical results from a series of patients with long-term facial paralysis who underwent facial reanimation between June 2016 and September 2019, through the insertion of the sternohyoid muscle into the masseteric nerve.

RESULTS

The anatomical study was conducted in eight human hemi-necks. In five cases (62%), the vascular pedicle was provided by the superior thyroid artery, and the entrance of the ansa cervicalis to the muscle was constant 1.8 cm from the distal insertion. This series included ten patients who underwent the surgery technique of facial reanimation using the sternohyoid muscle, with a 90% (n = 9) of reinnervation; 100% (n = 10) of flaps were viable, and none of the patients showed complications in the donor area.

CONCLUSIONS

The sternohyoid muscle showed itself as a reliable muscle as a free flap in facial reanimation, and alternative to the gracilis flap. The surgical technique was safe, without any complications, with excellent excursion, recovery, and aesthetic results.

M-Mode Echomyography of Facial Muscle Function Following Facial Reanimation with Temporalis Muscle Galea Pedicled Flap: Analysis of Ten Cases with Review of Literature

Introduction

Facial palsy is a condition where the patients lack voluntary movement on the affected side of the face and are not able to convey their emotions. Besides that, they also succumb themselves to social isolation. Various techniques have been devised to overcome this devastating problem. The aim of this article is to evaluate and compare facial muscle function before and after facial reanimation with temporalis muscle galea pedicled flap by motion mode echomyography in patients with long-standing facial paralysis.

Patients and Methods

Ten patients with long-standing facial paralysis were included in the study (six patients with LMN palsy and four patients with facial weakness involving specific peripheral branches), and they subsequently underwent facial reanimation surgery with temporalis galea pedicled flap. These patients were followed postoperatively for a period of 1-2 years and were subjectively graded as excellent, good, fair and poor and objectively evaluated by M-mode echomyography, and the results were evaluated and statistically analyzed.

Results

Subjectively, out of 6 patients with LMN palsy, results were graded as excellent in 2 cases, good in 3 cases, fair in 1 case, and out of 4 patients with weakness in specific facial nerve branches, the subjective results were excellent in 2 cases, good in 1 case and fair in 1 case. Objectively, the effect of transposed temporalis galea on orbicularis occuli, levator labii superioris and orbicularis oris was found to be statistically significant in patients with LMN palsy.

Conclusion

Our study proves the versatility of temporalis muscle galea pedicled flap in cases of long-standing facial paralysis by motion mode echomyography.

The mini-temporalis turnover flap for midface reanimation: Photogrammetric and patient-rated outcomes

BACKGROUND

Mini-temporalis transposition (MTT) flaps, modified from Gillies' technique, have become less popular than temporalis tendon transfers for midface reanimation. MTT involves raising the middle third of the temporalis, transposition over the zygomatic arch and lengthening with deep temporalis fascia which is sutured to the orbicularis oris.

AIM

This retrospective study assessed subjective and objective outcomes following MTTs by a single surgeon from 2009 to 2019.

METHODS

Operative and surgical details were recorded. Four blinded consultants rated pre- and postoperative videos according to Terzis' scale. Pre- and postoperative resting, Mona Lisa and canine smile photographs were analysed using Emotrics, the software that automatically computes differences in inter-landmark distances. Patients also completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.

RESULTS

Forty-one patients (mean age 65.8 ± 15.5) underwent MTT, median 3 (0.4-57) years post-paralysis and were followed up for median of 2.2 (0.4-8.8) years. Higher mean postoperative Terzis score demonstrates symmetric and aesthetic improvements (3 ± 1.3 vs. 2 ± 1; p<0.05). Emotrics analysis showed postoperative improvements in resting and dynamic symmetry of all indices, with the majority statistically significant (p<0.003). The mean GBI was 35.19 with 17 (94.4%) patients reporting improvement, whereas one (5.6%) patient reported detriment after surgery. Two (5.4%) patients suffered complications: one haematoma and one infection. Four patients (9.8%) required revisional flap tightening. No patients requested revisional surgery for temporal hollowing or zygomatic fullness.

CONCLUSIONS

MTT effectively improves both subjective and objective resting and dynamic midface symmetry in a single stage. These results suggest this technique is a good alternative to temporalis tendon transfer techniques.

One-stage reconstruction by dual-innervated double muscle flap transplantation with the neural interconnection between the ipsilateral masseter and contralateral facial nerve for reanimating established facial paralysis: A report of 2 cases

The authors developed a one-stage double-muscle reconstruction technique for facial paralysis using a latissimus dorsi (LD) flap and a serratus anterior (SA) flap, which were dually reinnervated by the contralateral facial nerve (FN) and ipsilateral masseter nerve (MN). The procedure was performed for 61-year-old man 3-years after resection of a malignant tumor and a 24-year-old woman 10-years after temporal fracture with facial paralysis. A double-muscle flap comprising left LD and SA flaps was harvested, a 15-cm thoracodorsal nerve (TN) section was attached to the LD flap, and 5-cm and 1-cm sections of the long thoracic nerve (LTN) were attached to the proximal and distal sides of SA flap. The LD flap and SA flap were sutured along the direction of motion of the zygomaticus major and risorius muscles, respectively. The contralateral FN and ipsilateral MN were interconnected by nerve suturing: the medial branch of TN to the distal end of LTN, the proximal end of LTN to the ipsilateral MN, and the buccal branch of contralateral FN to the main trunk of TN. After surgery, good contraction of the transferred flaps resulted in reanimation of a natural symmetrical smile; no complications were observed during the 12-month follow-up period.

Outcome of a graduated minimally invasive facial reanimation in patients with facial paralysis

Peripheral paralysis of the facial nerve is the most frequent of all cranial nerve disorders. Despite advances in facial surgery, the functional and aesthetic reconstruction of a paralyzed face remains a challenge. Graduated minimally invasive facial reanimation is based on a modular principle. According to the patients' needs, precondition, and expectations, the following modules can be performed: temporalis muscle transposition and facelift, nasal valve suspension, endoscopic brow lift, and eyelid reconstruction. Applying a concept of a graduated minimally invasive facial reanimation may help minimize surgical trauma and reduce morbidity. Twenty patients underwent a graduated minimally invasive facial reanimation. A retrospective chart review was performed with a follow-up examination between 1 and 8 months after surgery. The FACEgram software was used to calculate pre- and postoperative eyelid closure, the level of brows, nasal, and philtral symmetry as well as oral commissure position at rest and oral commissure excursion with smile. As a patient-oriented outcome parameter, the Glasgow Benefit Inventory questionnaire was applied. There was a statistically significant improvement in the postoperative score of eyelid closure, brow asymmetry, nasal asymmetry, philtral asymmetry as well as oral commissure symmetry at rest (p < 0.05). Smile evaluation revealed no significant change of oral commissure excursion. The mean Glasgow Benefit Inventory score indicated substantial improvement in patients' overall quality of life. If a primary facial nerve repair or microneurovascular tissue transfer cannot be applied, graduated minimally invasive facial reanimation is a promising option to restore facial function and symmetry at rest.

Double innervated free functional muscle transfer for facial reanimation

BACKGROUND

The treatment of long-standing facial palsy represents a challenge for the reconstructive surgeon. Treatment is based on dynamic procedures such as functional muscle flaps. The benefit of added axonal load has recently been reported. This study describes a two stage technique involving dual innervation of a gracilis muscle flap with initial cross-facial nerve graft (CFNG) followed by free muscle transfer co-apted to both the CFNG and a masseter nerve for facial reanimation.

METHODS

A total of nine patients from August 2008-July 2011 were operated on with the double innervated gracilis muscle flap. Pre- and postoperative electromyography was documented, and video analysis with the five-stage classification of reanimation outcomes was performed.

RESULTS

All patients recovered voluntary and spontaneous smile abilities, with an average of 70% motor unit recruitment. Based on the Terzis reanimation outcome classification, four patients had an excellent result, four good, and one moderate.

CONCLUSIONS

The double innervated gracilis muscle flap is a viable technique for the treatment of long-standing facial palsy. It enables a fast recovery with fast muscle activity, and allows an emotional smile and aesthetic symmetry.

Rehabilitation of congenital facial palsy with temporalis flap--case series and literature review

BACKGROUND

Congenital facial paralysis is a rare disorder with an incidence of less than 1 in 1000 live births. Several surgical rehabilitation techniques have been described, such as free flaps or transpositions of the temporalis muscle. We report our experience of transposition of the temporalis muscle in this indication.

MATERIALS AND METHODS

Retrospective monocentric study between January 2005 and December 2009.

RESULTS

Five children (mean age at the surgery: 7.3 years, range 6-13) presenting with a congenital facial paralysis were treated by a temporalis muscle transposition during the considered period. An etiological assessment was achieved by carrying out a petrous bone CT, a cerebral and petrous MRI, and audiometric evaluation. Four patients out of 5 (80%) showed a satisfactory and stable functional outcome over time (average follow-up: 26 months).

CONCLUSION

Temporalis muscle transposition is a single-stage procedure, easily adapted for the pediatric condition of congenital facial paralysis. It is our opinion that this procedure needs to be carried out at the end of the pre-school period.

Double innervation in free-flap surgery for long-standing facial paralysis

OBJECTIVE

One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch.

METHODS

Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve.

RESULTS

All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes.

CONCLUSIONS

In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

Surgical management of facial nerve paralysis in the pediatric population

BACKGROUND

In the pediatric patient population, both the pathology and the surgical managements of seventh cranial nerve palsy are complicated by the small size of the patients. Adding to the technical difficulty is the relative infrequency of the diagnosis, thus making it harder to become proficient in the management of the condition. The magnitude of the functional and aesthetic deficits these children manifest is significantly troubling to both the patient and the parents, which makes immediate attention, treatment, and functional restoration essential.

METHODS

A literature search using PubMed (http://www.pubmed.org) was undertaken to identify the current state of surgical management of pediatric facial paralysis.

RESULTS

Although a multitude of techniques have been used, the ideal reconstructive procedure that addresses all of the functional and cosmetic needs of these children has yet to be described. Certainly, future research and innovative thinking will yield progressively better techniques that may, one day, emulate the native facial musculature with remarkable precision.

CONCLUSION

The necessity for surgical intervention in children with facial nerve paralysis differs depending on many factors including the acute/chronic nature of the defect as well as the extent of functional and cosmetic damage. In this article, we review the surgical procedures that have been used to treat pediatric facial nerve paralysis and provide therapeutic facial reanimation.

Facial Attractiveness

Symmetry is thought to be a major prerequisite for an attractive face. Many faces are not symmetric, yet are still regarded as beautiful. What role, then, does asymmetry play in the perception of beauty? We studied the assessment of computer-manipulated images by independent judges (n = 200-250): part A: nevi located at different positions; part B: standardized changes of the orbital region. The results showed that slight lateral orbital and facial asymmetry does not impair attractiveness at all and that asymmetries close to the midline are significantly less attractive than those affecting the lateral aspect of the face (P < 0.001). A single nevus which is located laterally on the face is significantly more attractive than a nevus close to the midline (P < 0.001). Faces with a completely symmetric bilateral pair of nevi in the same lateral positions (perceived as attractive when alone), received the worst ratings (P < 0.001). Symmetry is a characteristic of the attractive face, but there are exceptions to the rule. Under certain conditions symmetry can be completely unattractive. The visual impact of symmetry on the perception of beauty increases significantly when approaching the midline.

Rehabilitation of Long-standing Facial Nerve Paralysis With Percutaneous Suture–Based Slings

Long-standing facial paralysis creates significant functional and aesthetic problems for patients affected by this deficit. Traditional approaches to correct this problem have involved aggressive open procedures such as unilateral face-lifts and sling procedures using fascia and implantable materials. Unfortunately, our results with these techniques over the last 5 years have been suboptimal. The traditional face-lift techniques did not address the nasolabial fold to our satisfaction, and suture-based techniques alone, while offering excellent short-term results, failed to provide a long-term solution. This led to the development of a novel percutaneous technique combining the minimally invasive approach of suture-based lifts with the long-term efficacy of Gore-Tex-based slings. We report our results with this technique for static facial suspension in patients with long-standing facial nerve paralysis and our surgical outcomes in 13 patients. The procedure offers re-creation of the nasolabial crease and suspension of the oral commissure to its normal anatomic relationships. The recovery time is minimal, and the operation is performed as a short outpatient procedure. Long-term 2-year follow-up has shown effective preservation of the surgical results.

Multimodality Approach to Management of the Paralyzed Face

OBJECTIVES

Despite the ability of facial reanimation techniques to introduce meaningful movement to the paralyzed face, dynamic methods do not address all zones of the face. Our objective was to retrospectively review outcomes after multimodality management of the patient with facial paralysis, to describe several novel surgical methods that introduce subtle improvements in static facial balance, and to present an algorithm for comprehensive management of the paralyzed face.

METHODS/RESULTS

Three hundred thirty-seven patients with facial paralysis were seen and treated in a busy facial nerve center setting over a 3-year period using a range of standard muscle transfers, physical therapy, chemodenervation with botulinum toxin, and static surgical techniques. Three adjunct techniques emerged as novel and useful procedures that more fully addressed facial balance issues than existing techniques. Of patients proceeding with physical therapy, greater than 80% of patients experienced a benefit, and 97% of those who proceeded with botulinum toxin therapy experienced a benefit.

CONCLUSIONS

Facial paralysis is best managed using a multimodality approach that includes surgical interventions, physical therapy, and chemodeneveration. We describe three adjunctive surgical techniques for management of the paralyzed face and present a comprehensive algorithm for management of the paralyzed face. That may provide improved function and cosmesis in all zones of the paralyzed face.

Advances in facial reanimation

PURPOSE OF REVIEW

Facial paralysis often has a significant emotional impact on patients. Along with the myriad of new surgical techniques in managing facial paralysis comes the challenge of selecting the most effective procedure for the patient. This review delineates common surgical techniques and reviews state-of-the-art techniques.

RECENT FINDINGS

The options for dynamic reanimation of the paralyzed face must be examined in the context of several patient factors, including age, overall health, and patient desires. The best functional results are obtained with direct facial nerve anastomosis and interpositional nerve grafts. In long-standing facial paralysis, temporalis muscle transfer gives a dependable and quick result. Microvascular free tissue transfer is a reliable technique with reanimation potential whose results continue to improve as microsurgical expertise increases. Postoperative results can be improved with ancillary soft tissue procedures, as well as botulinum toxin.

SUMMARY

The paper provides an overview of recent advances in facial reanimation, including preoperative assessment, surgical reconstruction options, and postoperative management.